HISTORY OF HIV IN SA
A brief history of South Africa’s response to AIDS
N P Simelela,1 MB ChB, MMed; W D F Venter,2 FCP (SA)
1
2
S pecial Adviser on Health Matters within the Presidency and former Chief Director of HIV & AIDS within the National Department of Health
W
its Reproductive Health and HIV Institute and Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
Corresponding author: N P Simelela (nonosimelela@gmail.com)
The story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic
denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million
people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated
number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years
are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level
since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in
life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared
to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile
system to bring about change.
S Afr Med J 2014;104(3 Suppl 1):249-251. DOI:10.7196/SAMJ.7700
South Africa (SA) is home to the largest concentration
of people living with HIV anywhere in the world.
Almost 20% of all HIV-positive persons globally live
within our borders, and preliminary data from the
as yet unreleased 2012 Human Sciences Research
Council South African National Household Survey reveal that >6.4
million people in SA – 19.6% of all adults or 12.3% of the total
population – live with the virus.[1]
The first AIDS-related deaths in SA occurred in late December
1981 and January 1982, with very limited attention to the epidemic
over the next decade.[2,3] The dawn of a new democracy in 1994
brought optimism regarding the future of the country, and the new
administration had to redesign every tier of government in the
context of a fractured governance system that included the so-called
‘Bantustans’. The HIV epidemic was not an issue of major concern
and therefore received very limited attention in the initial flurry of
setting up a democratic government.
Civil society created a National Advisory Group (Networking
HIV/AIDS Community of South Africa (NACOSA)) to lobby for and
ultimately to draft a national AIDS plan. This plan was accepted by
the new government 3 months into its term of office in 1994.[2] HIV
prevalence subsequently rose from 0.8% in 1990 to 4.3% by 1994, and
now rests at 12.3% of the total population.[1] Tragically, 1998 - 2008
was to prove a testing period for the country as the full extent of the
epidemic’s health impact became apparent, in the face of President
Thabo Mbeki’s increasingly apparent denialism.[4]
The beginning of a prevention and
treatment response
Given the limited knowledge regarding HIV transmission dynamics, the
mainstay of the response during the 1980s and 1990s was the provision
of condoms and a ‘safe-sex’ education strategy hampered by stigma, fear
and other behavioural and social factors. Efforts to communicate were
additionally impeded by controversies around the Sarafina II play[5] and
the Virodene scandals.[2] Efforts to mitigate the impact of the epidemic
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included a strategy for home-based care for the large number of people
who had advanced AIDS, and strategies for affected children.
The second phase of the prevention response followed, with trials
examining the effectiveness of antiretrovirals (ARVs) delivered to
pregnant women and their neonates (prevention of mother-to-child
transmission (PMTCT)), and ushered in an era of heightened conflict. [6,7]
The SA government declared that a phased piloting approach was
needed, and ‘there was enough scientific evidence confirming the
efficacy of ARVs in reducing the transmission of HIV from mother
to child that it should be implemented within the region immediately,
but the operational challenges of actually introducing PMTCT needed
to be assessed in both rural and urban settings’; this phased approach
was seen as an attempt to hamper expanding rapid access to effective
PMTCT. The decision came at the height of civil society’s clash with
Mbeki’s administration over widely criticised denialism on the issue of
HIV/AIDS, including denial of a causal link between HIV and AIDS.
Civil society challenged the policy in the High Court, arguing
that the refusal to provide nevirapine for the PMTCT violated the
Constitution. The Pretoria High Court ruled that ‘[a] countrywide
PMTCT programme is an ineluctable obligation of the state’. The
Minister of Health appealed this ruling directly to the Constitutional
Court, claiming that an appeal was necessary to ‘[clarify] a
constitutional and jurisdictional matter which, if left vague, could
throw executive policy making into disarray and create confusion
about the principle of the separation of powers, which is a cornerstone
of our democracy’.[7]
During the appeal, a Health Systems Trust report commissioned
by the National Department of Health (NDoH) stated categorically
that ‘There are no good reasons for delaying a phased expansion of
PMTCT services in all provinces’, and recommended that ‘nevirapine
can and should be provided immediately’.[8] Gauteng and KwaZuluNatal provinces broke ranks with Minister of Health (MoH),
Dr Manto Tshabalala-Msimang, and announced decisions to expand
their PMTCT pilot programmes.[9] Even though the Gauteng Premier
received a public rebuke from the MoH and gave the appearance of
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HISTORY OF HIV IN SA
backing down, it was soon announced that PMTCT was available
at 70% of public healthcare facilities in Gauteng. The Minister lost
the appeal in a historic judgment that remains unprecedented in its
criticism of the government.[7]
In the face of sustained national and international criticism, as
well as internal dissent, and as countries in southern Africa began
announcing public antiretroviral therapy (ART) programmes, a
Cabinet statement released in April 2002 ‘reiterated government’s
commitment to the HIV & AIDS and STI Strategic Plan for South
Africa, 2000 - 2005’ and affirmed that ‘government’s starting point
is based on the premise that HIV causes AIDS’.[10] This statement
signalled a sea-change within the government on HIV. The same
Cabinet meeting called on the NDoH to develop a rollout plan
for the PMTCT and, unexpectedly, to prepare ‘a protocol for a
comprehensive package of care for survivors of sexual assault,
including post-exposure prophylaxis with ARV drugs’ which would,
for the first time, make prophylaxis available to survivors of sexual
assault in public healthcare facilities across all nine provinces.
The development of an ART programme
Later in April 2002, the SA government established a Joint Health
and Treasury Task Team to propose options for expanding the HIV
treatment response beyond PMTCT and post-exposure prophylaxis.
Clinicians in the joint task team quietly developed HIV treatment
protocols that included ART for adults and children. Assistance from
the Clinton Foundation and other international agencies, including
donors such as the US President’s Emergency Plan for AIDS Relief
(PEPFAR), allowed this work to progress rapidly. In August 2003
Cabinet received the joint Health and Treasury Task Team report. [11]
The Cabinet meeting reaffirmed the government’s position on the
causal link between HIV and AIDS, and instructed the NDoH to
develop ‘as a matter of urgency’ a detailed operational plan for a
nationwide ART programme.[12]
In November 2003 the Operational Plan for Comprehensive HIV
and AIDS Care, Management and Treatment for South Africa[13] was
presented to and approved by Cabinet.[14,15] Finally, on 1 April 2004,
ARV initiation began at several service points across the country.
Facilities had to be ‘accredited’, needing to pass an exhaustive
examination of 23 different criteria.[14,16] The intention behind the
accreditation was to enable facilities to prepare adequately, but
the process slowed down the pace of expansion considerably. The
implementation approach created significant verticalisation of the
programme and set the tone of the response, requiring teams
of specialist healthcare workers and complicated bureaucratic
procedures, and putting challenging staffing and infrastructure
obstacles in the way of delivery.
The ART programme begins
By March 2005, the target of the comprehensive plan – to have at
least one service point for AIDS-related care and treatment in each of
the country’s 53 districts – had been met. It took 12 months after the
rollout began, and was more than 2 years after the Operational Plan was
developed, to meet this target. All provinces had begun providing ART,
but this was largely through hospitals, a large number of them tertiary
facilities. The number of people actually receiving ART remained far
below what had been targeted. By September 2005, 17 months after
rollout began, 85 000 people were enrolled on ART in the public
health sector. By then, 199 public healthcare facilities (just over 5%)
were providing ARVs for the treatment of HIV.[16] The NDoH issued a
directive in 2005 instructing facilities that possession of an ID book was
not a requirement for treatment, allowing foreign nationals to access
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the ART programme. Donors such as PEPFAR and the Global Fund
continued to support a broad array of interventions, including support
to large non-governmental organisations, to support and provide care.
In 2006, Cabinet signed off on the new National Strategic Plan (NSP)
for HIV & AIDS and STIs, 2007 - 2011, prepared by the South African
National AIDS Council (SANAC) in a laborious, politically charged
but widely consultative process. The NSP ambitiously committed the
government to providing ARVs to 80% of those eligible. By December
2007, an estimated 424 009 patients were receiving ARVs.
The year 2008 was a landmark for the HIV programme. A
leadership transition in the ANC saw the resignation of President
Mbeki and his MoH and the installation of an interim government
between September 2008 and May 2009. By December 2008, the
estimated number of patients on ARVs had grown to 678 550.
In May 2009, the newly installed President Jacob Zuma immediately
acknowledged HIV as among the most important challenges facing
the country, and Dr Aaron Motsoaledi, appointed as MoH, brought
an urgency and a renewed focus to the HIV response. The new
MoH began his tenure by frankly acknowledging that SA’s healthcare
system had spent the last ‘10 years pedalling backwards’[17] and began
freely citing the extensive HIV data available from the SA research
community, as well as several highly influential and critical reviews
on the country’s health system published in The Lancet. During his
address to the National Council of Provinces in 2009, the President
highlighted ‘the chilling statistics that demonstrate the devastating
impact that HIV and AIDS is having on our nation’. He declared
World AIDS Day 2009 as ‘the day on which we start to turn the tide
in the battle against AIDS’.
With the number of patients on ARVs estimated to be >900 000,
SA launched a massive national HIV counselling and testing (HCT)
campaign. The sheer scale of patients anticipated to be identified by
the campaign led to the announcement that accreditation would be
abandoned and that all public healthcare facilities would be geared
up to provide ARVs. As part of the HCT campaign, the President
publicly tested for HIV, among the 20 million South Africans to learn
their status over the next 20 months.
This announcement included the declaration that the country
would launch a medical male circumcision drive, with KwaZuluNatal the first province to roll this out at scale, although this process
was hampered by controversy over the use of a circumcision device
that many felt was unsafe. By the end of 2010, 131 117 men had been
circumcised. At the end of the year, in sharp contrast to the booing
President Mbeki had received at the 2000 AIDS Conference, the
Deputy President and MoH received a standing ovation at the Vienna
AIDS conference after presenting the significant progress made in
expanding access to treatment in SA.
With far less drama than had accompanied previous HIV guideline
revisions, and signalling the ‘normalisation’ of the HIV policy response,
the NDoH published guidelines relating to tuberculosis, PMTCT, HCT,
community caregivers and circumcision, and moved towards ‘task
sharing’ as part of primary healthcare restructuring. The year 2009 also
saw the restructuring and strengthening of the SANAC, responsible for
better co-ordination between civil society and government. The NDoH
also revised the ARV guidelines in 2010, expanding treatment to all
children under 1 year, all pregnant women regardless of CD4+ count
and all TB-HIV co-infected patients with a CD4+ count of <350 cells/
µl, and changing ART for both first- and second-line therapy to make
it safer, if more expensive. Only 55% of adults and 36% of children
eligible for ART were receiving it by the end of 2010.
On World AIDS Day 2011, SA launched a third NSP for 2012 2016, which included a strong focus on marginalised groups such as
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HISTORY OF HIV IN SA
sex workers, men who have sex with men, truckers and adolescents. [13]
The head of the NDoH’s HIV programme pointed to the dramatic
acceleration of the programme, stating: ‘It’s actually quite extraordinary
that in 2004 we had only 47 000 people on treatment … By mid-2011,
we had 1.79 million people. It’s almost a city.’[18] In 2012, a decision was
made to increase the initiation threshold to 350 cells/µl for all adults,
as well as to expand access thresholds for children. By mid-2013, 6.4
million people were estimated to be living with HIV in SA, with an
estimated 2.3 million on ART, and expanded access to ‘third-line’ drugs
for patients experiencing resistance.
Conclusion
Huge challenges remain for the HIV response. HIV care provision
requires a functional healthcare service, and failures threaten the
existing and further scale-up of ARV care. Having access to worldclass medication and initiation thresholds is small comfort when
reports from across the country of drug stock-outs suggest a major
problem in supply systems well beyond HIV care.[19] Some high-risk
sexual behaviours seem to be on the rise.[1] Key populations, such
as sex workers, men who have sex with men, truckers, adolescents,
heterosexual men and others are not accessing services enough.
Addressing the structural factors that increase vulnerability is the
main focus of the development agenda going forward. Enablers such
as poverty, unemployment, alcohol abuse, gender violence, teenage
pregnancy and access to evidence-based interventions such as male
circumcision and condoms need to be addressed. Monitoring and
evaluation remain rudimentary, with constant speculation that high
initiation numbers mask large numbers of patients lost to follow-up.
Cost remains an issue.[20] In retrospect, the progressive evolution of
the HIV and AIDS conditional grant over several years into a flexible,
simplified funding mechanism was probably critical to finding a
financing vehicle capable of successfully channelling hundreds of
millions of rands into the new comprehensive treatment programme
in the space of just a year or two. This had not been the deliberate
intent of those who had nurtured the grant from a R16 million infant
to the R8.7 billion behemoth it has become in 2013/14,[21] but the
grant mechanism appears to have endured successfully.
Since 2009, a new administration has rapidly normalised the
response to the epidemic. The political and science battles appear
largely to have been fought;[22,23] the harder job of ensuring a system
of delivery that secures decades of effective HIV prevention and care
now looms as possibly the greater challenge.
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Acknowledgments. NPS writes in her personal capacity. WDFV is
supported by PEPFAR.
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